SUMMARY Background/Aim: Dental fluorosis is a specific disturbance of tooth formation caused by excessive intake of fluoride. The discoloration of teeth is the most common reason for parents to seek treatment. The purpose of this paper is to describe the therapeutic management performed in a 9-year-old girl with fluorosis. Case report: A clinical case of a 9-year-old girl diagnosed with fluorosis is reported. The treatment of this clinical case was achieved using microabrasion, which is a minimally invasive method. This technique improves the aesthetics of the teeth without causing significant loss of dental tissue; a characteristic making microabrasion applicable to children as well. Its implementation involved the combined use of 18% hydrochloric acid and pumice on the enamel surface of upper incisors. The improved appearance of the teeth was aesthetically pleasing and, consequently, the patient gained in self-confidence. Conclusions: In the literature, several treatment choices are proposed, depending on the severity of the fluorosis. In our case, microabrasion was applied and the aesthetic outcome satisfied both the patient and the dentist. Key words: Fluorosis, Bleaching, Microabrasion, Treatment, Discoloration Zoi Daskalaki 1 , Evgenia Alifakioti 2 , Aristidis Arhakis 2 1 School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece 2 Department of Pediatric Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece CASE REPORT (CR) Balk J Dent Med, 2019;157-162 BALKAN JOURNAL OF DENTAL MEDICINE ISSN 2335-0245 Aesthetic Treatment of Dental Fluorosis in a 9-Year-Old Girl: Case Report S T O M A T O L O G I C A L S O C I E T Y Introduction Dental fluorosis is a disorder caused by chronic excessive fluoride intake during the period of the development of the teeth 1 . In 1931, three different scientific groups, working in different locations around the world, discovered the correlation between the fluoride content in drinking water and dental fluorosis 2-4 . The use of fluoride in preventive dentistry has been shown to be the most effective measure against dental caries, yet it is also associated with the increased prevalence of dental fluorosis in many countries. It has been proven that exposure to 1 ppm fluoride in drinking water reduces the caries increment by 50-60% 5,6 . When the fluoride in potable water exceeds 1,5 ppm, aesthetic problems usually appear on tooth surfaces 7 . Water is the most common source for fluoride intake 8,9 . In addition, fluoride can also be found in drinks 10,11 , toothpaste 12 and infant formulas 13,14 . Specifically, the exposure of young children (for example, 0-3 years old) to fluoride through toothpaste, has been associated with a high prevalence of dental fluorosis 15 . In the literature, a few indices have been suggested to describe and classify enamel fluorosis 16,17 . Nowadays the most commonly used are Dean’s Index (DFI) 18 and Thylstrup and Fejerskov Fluorosis Index (TFI) 19 . Dean’s Index 18 rates the clinical image of the two most affected teeth. As a result, based on the severity, the case is rated as normal (0), questionable (0.5), very mild (1), mild (2), moderate (3) and severe (4). In questionable dental fluorosis there are minor aberrations from the usual translucency of the enamel, while opaque, paper- white areas are typical findings in very mild (<25% of the surface), mild (25<x<50% of the surface) and moderate dental fluorosis (100% of the surface). Moreover, in severe cases the entire enamel surface is affected and the most common feature is discrete or confluent pitting. On the other hand, the Thylstrup and Fejerskov Index 19 , which was modified in 1988, can measure the severity of fluorosis in a single tooth. This makes it suitable for determining the clinical management, even for a single infected tooth. Depending on the severity of 10.2478/bjdm-2019-0028
Aesthetic Treatment of Dental Fluorosis in a 9-Year-Old Girl: Case Report
Dec 16, 2022
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
SUMMARY Background/Aim: Dental fluorosis is a specific disturbance of tooth
formation caused by excessive intake of fluoride. The discoloration of teeth is the most common reason for parents to seek treatment. The purpose of this paper is to describe the therapeutic management performed in a 9-year-old girl with fluorosis. Case report: A clinical case of a 9-year-old girl diagnosed with fluorosis is reported. The treatment of this clinical case was achieved using microabrasion, which is a minimally invasive method. This technique improves the aesthetics of the teeth without causing significant loss of dental tissue; a characteristic making microabrasion applicable to children as well. Its implementation involved the combined use of 18% hydrochloric acid and pumice on the enamel surface of upper incisors. The improved appearance of the teeth was aesthetically pleasing and, consequently, the patient gained in self-confidence. Conclusions: In the literature, several treatment choices are proposed, depending on the severity of the fluorosis. In our case, microabrasion was applied and the aesthetic outcome satisfied both the patient and the dentist. Key words: Fluorosis, Bleaching, Microabrasion, Treatment, Discoloration
Zoi Daskalaki1, Evgenia Alifakioti2, Aristidis Arhakis2
1 School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece 2 Department of Pediatric Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
CASE REPORT (CR) Balk J Dent Med, 2019;157-162
BALKAN JOURNAL OF DENTAL MEDICINE ISSN 2335-0245
Aesthetic Treatment of Dental Fluorosis in a 9-Year-Old Girl: Case Report
STOMATOLOGIC A
L S
O C
IE T
Y
Introduction
Dental fluorosis is a disorder caused by chronic excessive fluoride intake during the period of the development of the teeth1. In 1931, three different scientific groups, working in different locations around the world, discovered the correlation between the fluoride content in drinking water and dental fluorosis2-4.
The use of fluoride in preventive dentistry has been shown to be the most effective measure against dental caries, yet it is also associated with the increased prevalence of dental fluorosis in many countries. It has been proven that exposure to 1 ppm fluoride in drinking water reduces the caries increment by 50-60%5,6. When the fluoride in potable water exceeds 1,5 ppm, aesthetic problems usually appear on tooth surfaces7. Water is the most common source for fluoride intake8,9. In addition, fluoride can also be found in drinks10,11, toothpaste12 and infant formulas13,14. Specifically, the exposure of young children (for example, 0-3 years old) to fluoride through toothpaste, has been associated with a high prevalence
of dental fluorosis15. In the literature, a few indices have been suggested to describe and classify enamel fluorosis16,17. Nowadays the most commonly used are Dean’s Index (DFI)18 and Thylstrup and Fejerskov Fluorosis Index (TFI)19.
Dean’s Index18 rates the clinical image of the two most affected teeth. As a result, based on the severity, the case is rated as normal (0), questionable (0.5), very mild (1), mild (2), moderate (3) and severe (4). In questionable dental fluorosis there are minor aberrations from the usual translucency of the enamel, while opaque, paper- white areas are typical findings in very mild (<25% of the surface), mild (25<x<50% of the surface) and moderate dental fluorosis (100% of the surface). Moreover, in severe cases the entire enamel surface is affected and the most common feature is discrete or confluent pitting.
On the other hand, the Thylstrup and Fejerskov Index19, which was modified in 1988, can measure the severity of fluorosis in a single tooth. This makes it suitable for determining the clinical management, even for a single infected tooth. Depending on the severity of
10.2478/bjdm-2019-0028
158 Zoi Daskalaki et al. Balk J Dent Med, Vol 23, 2019
improvement in the girl’s self-esteem through improving appearance of her smile was considered to be essential. On account of the fact that the patient was quite young, the dentist decided to perform microabrasion on the upper incisors, since it is a minimally invasive technique for removing white opaque spots from the enamel surface.
A rubber dam was applied to protect soft issues and ensure a dry and clean operating field, and biofilm was removed from the upper incisors by dental prophylaxis. Then, a paste of 18% hydrochloric acid and pumice slurry was applied on the labial surface of the incisors. The outer surface of the enamel was abraded with the use of a rotating brush at low speed (Figure 2). After 5 seconds of performing the abrasion, the paste was rinsed off and the enamel surface was reevaluated (Figure 3). Following the same method, a second application was performed (Figure 4), in the case of the upper right central incisor, a third application was considered to be necessary (#11). Finally, a 2% neutral sodium fluoride gel was applied for 4 minutes so as to prevent postoperative sensitivity (Figure 5). After the completion of the treatment, a significant improvement in the appearance of the girl’s smile was achieved and the result satisfied both the patient and the dentist (Figure 6). No postoperative sensitivity or pain was mentioned by the patient. One year later she came to the dental office for the arranged follow-up and the tooth surfaces were found to remain even and glossy.
the situation, a score from 0 to 9 is given. Teeth scored with TFI 1-3 are characterized as mildly fluorosed, while teeth with TFI 4-5 are rated moderately fluorosed and teeth with TFI 6+ are the severe cases. More specifically, in mild dental fluorosis white opaque lines and even wider white opaque areas can be seen on the enamel. Furthermore, in moderate dental fluorosis the whole enamel surface is opaque, white and chalky and even exhibits pits. Finally, in severe dental fluorosis a part or even the whole enamel surface is lost.
The discoloured and porous enamel of fluorosed teeth can be aesthetically unsatisfactory, impacting on patient’s psychological state of mind20-22. It has been proposed that the repercussions resulting from the excessive intake of fluoride on soft tissues of children are reversible, on condition that there is a cessation of fluoride intake and the patients consume supplementary calcium, vitamin D3, ascorbic acid and antioxidants23,24. Nevertheless, there is no such evidence regarding hard tissues. Therefore, in most cases the therapeutic management of the cosmetic problem is needed, which should be as minimally invasive as possible. The aim of this study is to describe a clinical case of a 9-year- old girl, who was diagnosed with mild-to-moderate dental fluorosis, and the treatment procedure which was performed.
Case Report
A 9-year-old girl presented at a private dental office accompanied by her mother. Her medical and family history were unremarkable and the main reason for visiting the dentist was the child’s smile, which was characterized by white opaque spots on the upper and lower incisors. The patient was a resident of the town of Langadas, where the concentration of fluoride in the drinking water ranges from 0,3 to 15,5 ppm.
Figure 1. Clinical picture of the 9-year-old girl. Mild-to-moderate dental fluorosis
The clinical examination revealed that almost the entire enamel surface had a white, chalky appearance leading to a diagnosis of mild-to-moderate severity dental fluorosis, according to the TFI Index (Figure 1). An
Figure 2. The enamel was abraded with a paste of 18% hydrochloric acid and pumice slurry and a rotating brush at low speed
Figure 3. Appearance of the teeth after the 1st application
Balk J Dent Med, Vol 23, 2019 Treatment of Dental Fluorosis 159
the interaction between proteins and crystals is altered. Hydrolysis of the enamel matrix proteins is delayed. Therefore, they are retained in the matrix during the maturation stage. This causes a rise of pH that delays the modulation of ruffle-ended ameloblasts to the smooth- ended form which comprise the superficial layer of aprismatic enamel27. In the maturation stage, sustained exposure to fluoride leads to the formation of a highly hypomineralized subsurface enamel, which is responsible for the clinical appearance of opaque white areas26. Fluoride affects the ameloblasts. In fact, fluoride is responsible for subameloblastic cyst formation. These cysts can develop into deep cervical and shallow coronal pits at the enamel surface, while the underlying enamel is highly hypermineralized26,27. Excessive intake of fluoride during the formation of enamel has a negative effect on the enzymically breakdown and removal of amelogenins28,29. Protein and water retention prevents the formation of the crystals of the enamel matrix, resulting in a porous subsurface.
The volume and depth of the subsurface pores increase as the severity of dental fluorosis rises19. The more severe the dental fluorosis is, the more porous the enamel surface appears19. In mild cases, the enamel is characterized by white lines, following the perikymata. In several cases, the white lines are merged, whilst in other cases, clearly opaque areas can be seen in between them. In moderate cases, the whole enamel surface may be opaque and white. In view of the fact that concentration of fluoride in the water of the town of Langadas ranges from 0,3 to 15,5 ppm, while the acceptable level of fluoride in potable water has been found to be 1,5 ppm7, it stands to reason that our patient’s teeth had been affected to such an extent that almost the entire enamel surface appeared white and chalky. After tooth eruption, the porous subsurface of fluorosed enamel can absorb pigments, triggering tooth discoloration. In cases of wide porous areas, an occlusal trauma could lead to fragmentation and the detachment of enamel resulting in the creation of pits19. Pigments permeate the porous substrate of fluorosed enamel, causing discoloration to happen. The colour of the enamel varies from yellowish to bright brown, dark brown or even black. The more severe the dental fluorosis, the more porous the enamel subsurface19.
In the literature a variety of management options are presented. Akpata suggested that bleaching should be performed as a treatment option in cases of mild fluorosis (TFI 1-2), based on the theory that pigments can be located in the outer layer of the porous enamel subsurface, hence they can be easily dislodged with the use of a bleaching agent30. The application of phosphoric acid to the hypomineralized enamel facilitates the infiltration of the bleaching agent into the porous subsurface enamel. Atia and May suggested that bleaching, microabrasion or the combination of these two should be performed as a treatment option in cases of mild fluorosis (TFI 1-3) in
Figure 6. Final aesthetic result
Discussion
An aesthetic appearance of the teeth is the key to a beautiful smile and something valued by people of all ages and genders. Aesthetic problems could have a negative impact on a patient’s psychology, limiting their social life20-22,25.
Fluoride levels in plasma are associated with disturbances of amelogenesis. Studies in rat incisors suggest that chronic plasma levels of 2 μmol/L or peak levels over 10 μmol/L are able to cause dental fluorosis. The severity of the defect on ameloblasts and the enamel matrix depends on the dose and duration of fluoride exposure26. It has been suggested that in the secretory stage, hydroxyapatite crystals are formed with a higher fluoride content leading to a greater number of amelogenins binding to the crystals. Consequently,
Figure 4. Appearance of the teeth after the 2nd application
Figure 5. 2% neutral sodium fluoride gel
160 Zoi Daskalaki et al. Balk J Dent Med, Vol 23, 2019
treatment, suggested for the aesthetic improvement of teeth which have either innate spots (dental fluorosis) or exogenous spots on the surface of the enamel41-43. It is considered to be the treatment of choice for mild dental fluorosis (TFI=1-3), whilst it can also be applied in teeth with moderate fluorosis (TFI=4)30 and it is usually combined with bleaching in order to achieve a more effective result44. In comparison with other restorative procedures, microabrasion causes a minimal loss of dental structure, it does not inflict postoperative pain or sensitivity on the patient and, in most cases, it is accomplished in a single session, causing insignificant discomfort to patients42-46. In general, microabrasion is suggested when the depth of discoloration is a maximum of 0,2-0,3 mm47. The amount of enamel lost by microabrasion ranges from 12 μm to 200 μm and it is affected by the duration of the process35,48,49. Furthermore, it has been found that the concentration of Ca and P in the outer layer of enamel is significant lower in young patients (18-24 years old) than in the older ones (>55 years old). This fact indicates that conservative, minimally invasive procedures are preferable when treating children and adolescents50. The instant and stable results obtainable after the complete removal of the spots, rather than by covering them with restorative material42, and the lack of pulpal and periodontal irritation are among the benefits of this method42,46. Phosphoric acid etching is performed on surface of the discoloured tooth, followed by the application of a fine-gritted paste made of pumice slurry and 18% hydrochloric acid in order to abrade the enamel surface. It is a technique that removes the porous enamel in conjunction with the unwanted pigments. Pastes with a lower concentration of hydrochloric acid can be found on the market. For instance, Prema Compound (Premier Dental Company) contains 10% hydrochloric acid and a silicon carbide abrasive powder. In addition, Opalustre (Ultradent) is comprised of 6.6% hydrochloric acid and silicon carbide microparticles49,51. Due to the use of acid during the microabrasion, it is crucial to use a rubber dam throughout the procedure. Not only does it protect soft tissues from irritation, but it also prevents materials from falling into the patient’s mouth and limits any contact with saliva. The paste can be applied on the tooth surface with the help of a polishing cup or a rotating brush on low speed (approximately 100 rpm)52 or by slightly pressing a tongue depressor53. In our case, after microabrasion, a significant improvement in the colour of the upper incisors was noticeable and the tooth surface appeared sleek and glossy. The factors which contribute to this result are mild mechanical abrasion of the enamel surface combined with erosion by the acid. In addition, the application of amorphous calcium phosphate (ACP) is recommended so that postoperative hypersensitivity is avoided52. It should be also mentioned that the Casein phosphopeptide - Amorphous calcium phosphate Complex
the paediatric patient31. Bharath et al. proposed that mild and moderate fluorosis in children can be managed with microabrasion or McInnes solution bleaching (consisting of HCL36%, H2O230% and Diethyle Ether), since both of them achieve aesthetic results and an absence of postoperative sensitivity32. Moreover, Bussadori et al. performed bleaching on an 8-year-old boy with fluorosis33. They used a dual activation system with 35% hydrogen peroxide and achieved a satisfactory outcome. Furthermore, Atia and May mention that individual stains in mild fluorosis could also be managed with composite resin; however, the removal of the discoloured enamel or application of an opaquer should be performed beforehand31.
Another treatment choice, which is mentioned in the literature, is the resin infiltration technique34,35. It is actually a micro-invasive treatment for the management of non-cavicated lesions and its aim is the deep penetration of a light-curing resin into the porous enamel lesions, so as to fill them34. Consequently, teeth become less opaque white and there is an improvement in their appearance36. However, further research is required in this area.
Akpata suggested microabrasion for the treatment of TFI=4 scored teeth, as pigments could be found so deeply inside the porous subsurface enamel that it is fanciful to believe that they could be completely removed exclusively by bleaching30. Microabrasion removes the porous subsurface enamel and pigments simultaneously. Hence, with microabrasion, management of dental fluorosis would be as optimally preservative as possible. Similarly, Khandelwal et al. effectively performed microabrasion on a paediatric patient with moderate fluorosis37. This is a rather conservative technique and, should it fail to meet the patient’s requirements, some other more invasive methods may be required38. For instance, Wallace and Deery recommend the use of composite resin in cases of moderate and severe dental fluorosis where bleaching and microabrasion have failed to meet the patient’s and dentist’s expectations35.
For cases with TFI ≥5, Atia and May proposed that microabrasion should be followed up with composite resin veneers31. As regards teeth with TFI=5-7, which have lost more than 50% of their enamel surface, and teeth with TFI=8-9, application of ceramic veneers and crowns is recommended31,39,40. However, this technique should only be used in adults, due to the fact that immature teeth have a quite wide pulp chamber and the position of the gingival margin is not in a constant level yet31,35. Taking all of the above into consideration, the treatment options for discoloured fluorosed teeth are bleaching, microabrasion, resin infiltration, composite resin, aesthetic veneers and crowns. In the literature, the criteria for the application of these techniques vary.
Microabrasion is the controlled removal of superficial stains from the enamel. In the literature, it is the first choice for conservative, minimally invasive
Balk J Dent Med, Vol 23, 2019 Treatment of Dental Fluorosis 161
10. Zhang R, Cheng L, Zhang T, Xu T, Li M, Yin W, et al. Brick tea consumption is a risk factor for dental caries and dental fluorosis among 12-year-old Tebetan children in Ganzi. Environ Geochem Health, 2018. doi: 10.1007/s10653-018- 0216-7.
11. Lodi CS, Ramires I, Pessan JP, das Neves LT, Buzalaf MA. Fluoride concentrations in industrialized beverages consumed by children in the city of Bauru, Brazil. J Appl Oral Sci, 2007;15:209-212.
12. Pretty IA. High fluoride concentration toothpastes for children and adolescents. Caries Res, 2016;50:9-14.
13. Siew C, Strock S, Ristic H, Kang P, Chou HN, Chen JW, et al. Assessing the potential risk factor for enamel fluorosis: A preliminary evaluation of fluoride content in infant formulas. J Am Dent Assoc, 2009;140:1228-1236.
14. Zohoori FV, Omid N, Sanderson RA, Valentine RA, Maguire A. Fluoride retention in infants living in fluoridated and non-fluoridated areas: effects of weaning. Br J Nutr, 2019;121:74-81.
15. Burt BA. The changing patterns of systemic fluoride intake. J Dent Res, 1992;71:1228-1237.
16. Rozier RG. Epidemiological indices for measuring the clinical manifestations of dental fluorosis: Overview and critique. Adv Dent Res, 1994;8:39-55.
17. Granath L, Widenheim J, Birkhed D. Diagnosis of mild enamel fluorosis in permanent maxillary incisors using two scoring systems. Community Dent Oral Epidemiol, 1985;13:273-276.
18. Dean H. Classification of Mottled Enamel Diagnosis. J Am Dent Assoc, 1934;21:1421-1426.
19. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol, 1978;6:315-328.
20. Tellez M, Santamaria RM, Gomez J, Martignon S. Dental fluorosis, dental caries, and quality of life factors among schoolchildren in a Colombian fluorotic areal. Community Dent Health, 2012;29:95-99.
21. Nurelhuda N, Ahmed MF, Trovik TA, Åstrøm AN. Evaluation of oral health-related quality of life among Sudanese schoolchildren using Child-OIDP inventory. Health Qual Life Out, 2010;8:152. doi: 10.1186/1477-7525- 8-152
22. Nilchian F, Asgary I, Mastan F. The effect of dental fluorosis on the quality of life of female high school and precollege students of high fluoride-concentrated area. J Int Soc Prev Community Dent, 2018;8:314-319.
23. Gupta SK, Gupta RC, Seth AK, Gupta A. Reversal of fluorosis in children. Acta Paediatr Jpn, 1996;38:513-519.
24. Suscheela AK, Bhatnagar M. Reversal of fluoride induced cell injury through elimination of fluoride and consumption of diet rich in essential nutrients and antioxidants. Mol Cell Biochem, 2002;234:335-340.
25. Welbrury RR, Shaw L. A simple technique for removal of mottling, opacities and pigmentation from enamel. Dent Update, 1990;2013:161-163.
26. DenBesten P, Li W. Chronic Fluoride Toxicity: Dental Fluorosis. Monogr Oral Sci, 2011;22:81-96.
27. Bronckers AL, Lyaruu DM, DenBesten PK. The Impact of Fluoride on Ameloblasts and the Mechanisms of Enamel Fluorosis. J Dent Res, 2009;88:877-893.
(CPP-ACP) brings about a reduction in the white opacity of the fluorosed enamel, boosting the remineralization54,55.
The clinical dentist should be aware of all the possible treatment choices, be able to…
formation caused by excessive intake of fluoride. The discoloration of teeth is the most common reason for parents to seek treatment. The purpose of this paper is to describe the therapeutic management performed in a 9-year-old girl with fluorosis. Case report: A clinical case of a 9-year-old girl diagnosed with fluorosis is reported. The treatment of this clinical case was achieved using microabrasion, which is a minimally invasive method. This technique improves the aesthetics of the teeth without causing significant loss of dental tissue; a characteristic making microabrasion applicable to children as well. Its implementation involved the combined use of 18% hydrochloric acid and pumice on the enamel surface of upper incisors. The improved appearance of the teeth was aesthetically pleasing and, consequently, the patient gained in self-confidence. Conclusions: In the literature, several treatment choices are proposed, depending on the severity of the fluorosis. In our case, microabrasion was applied and the aesthetic outcome satisfied both the patient and the dentist. Key words: Fluorosis, Bleaching, Microabrasion, Treatment, Discoloration
Zoi Daskalaki1, Evgenia Alifakioti2, Aristidis Arhakis2
1 School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece 2 Department of Pediatric Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
CASE REPORT (CR) Balk J Dent Med, 2019;157-162
BALKAN JOURNAL OF DENTAL MEDICINE ISSN 2335-0245
Aesthetic Treatment of Dental Fluorosis in a 9-Year-Old Girl: Case Report
STOMATOLOGIC A
L S
O C
IE T
Y
Introduction
Dental fluorosis is a disorder caused by chronic excessive fluoride intake during the period of the development of the teeth1. In 1931, three different scientific groups, working in different locations around the world, discovered the correlation between the fluoride content in drinking water and dental fluorosis2-4.
The use of fluoride in preventive dentistry has been shown to be the most effective measure against dental caries, yet it is also associated with the increased prevalence of dental fluorosis in many countries. It has been proven that exposure to 1 ppm fluoride in drinking water reduces the caries increment by 50-60%5,6. When the fluoride in potable water exceeds 1,5 ppm, aesthetic problems usually appear on tooth surfaces7. Water is the most common source for fluoride intake8,9. In addition, fluoride can also be found in drinks10,11, toothpaste12 and infant formulas13,14. Specifically, the exposure of young children (for example, 0-3 years old) to fluoride through toothpaste, has been associated with a high prevalence
of dental fluorosis15. In the literature, a few indices have been suggested to describe and classify enamel fluorosis16,17. Nowadays the most commonly used are Dean’s Index (DFI)18 and Thylstrup and Fejerskov Fluorosis Index (TFI)19.
Dean’s Index18 rates the clinical image of the two most affected teeth. As a result, based on the severity, the case is rated as normal (0), questionable (0.5), very mild (1), mild (2), moderate (3) and severe (4). In questionable dental fluorosis there are minor aberrations from the usual translucency of the enamel, while opaque, paper- white areas are typical findings in very mild (<25% of the surface), mild (25<x<50% of the surface) and moderate dental fluorosis (100% of the surface). Moreover, in severe cases the entire enamel surface is affected and the most common feature is discrete or confluent pitting.
On the other hand, the Thylstrup and Fejerskov Index19, which was modified in 1988, can measure the severity of fluorosis in a single tooth. This makes it suitable for determining the clinical management, even for a single infected tooth. Depending on the severity of
10.2478/bjdm-2019-0028
158 Zoi Daskalaki et al. Balk J Dent Med, Vol 23, 2019
improvement in the girl’s self-esteem through improving appearance of her smile was considered to be essential. On account of the fact that the patient was quite young, the dentist decided to perform microabrasion on the upper incisors, since it is a minimally invasive technique for removing white opaque spots from the enamel surface.
A rubber dam was applied to protect soft issues and ensure a dry and clean operating field, and biofilm was removed from the upper incisors by dental prophylaxis. Then, a paste of 18% hydrochloric acid and pumice slurry was applied on the labial surface of the incisors. The outer surface of the enamel was abraded with the use of a rotating brush at low speed (Figure 2). After 5 seconds of performing the abrasion, the paste was rinsed off and the enamel surface was reevaluated (Figure 3). Following the same method, a second application was performed (Figure 4), in the case of the upper right central incisor, a third application was considered to be necessary (#11). Finally, a 2% neutral sodium fluoride gel was applied for 4 minutes so as to prevent postoperative sensitivity (Figure 5). After the completion of the treatment, a significant improvement in the appearance of the girl’s smile was achieved and the result satisfied both the patient and the dentist (Figure 6). No postoperative sensitivity or pain was mentioned by the patient. One year later she came to the dental office for the arranged follow-up and the tooth surfaces were found to remain even and glossy.
the situation, a score from 0 to 9 is given. Teeth scored with TFI 1-3 are characterized as mildly fluorosed, while teeth with TFI 4-5 are rated moderately fluorosed and teeth with TFI 6+ are the severe cases. More specifically, in mild dental fluorosis white opaque lines and even wider white opaque areas can be seen on the enamel. Furthermore, in moderate dental fluorosis the whole enamel surface is opaque, white and chalky and even exhibits pits. Finally, in severe dental fluorosis a part or even the whole enamel surface is lost.
The discoloured and porous enamel of fluorosed teeth can be aesthetically unsatisfactory, impacting on patient’s psychological state of mind20-22. It has been proposed that the repercussions resulting from the excessive intake of fluoride on soft tissues of children are reversible, on condition that there is a cessation of fluoride intake and the patients consume supplementary calcium, vitamin D3, ascorbic acid and antioxidants23,24. Nevertheless, there is no such evidence regarding hard tissues. Therefore, in most cases the therapeutic management of the cosmetic problem is needed, which should be as minimally invasive as possible. The aim of this study is to describe a clinical case of a 9-year- old girl, who was diagnosed with mild-to-moderate dental fluorosis, and the treatment procedure which was performed.
Case Report
A 9-year-old girl presented at a private dental office accompanied by her mother. Her medical and family history were unremarkable and the main reason for visiting the dentist was the child’s smile, which was characterized by white opaque spots on the upper and lower incisors. The patient was a resident of the town of Langadas, where the concentration of fluoride in the drinking water ranges from 0,3 to 15,5 ppm.
Figure 1. Clinical picture of the 9-year-old girl. Mild-to-moderate dental fluorosis
The clinical examination revealed that almost the entire enamel surface had a white, chalky appearance leading to a diagnosis of mild-to-moderate severity dental fluorosis, according to the TFI Index (Figure 1). An
Figure 2. The enamel was abraded with a paste of 18% hydrochloric acid and pumice slurry and a rotating brush at low speed
Figure 3. Appearance of the teeth after the 1st application
Balk J Dent Med, Vol 23, 2019 Treatment of Dental Fluorosis 159
the interaction between proteins and crystals is altered. Hydrolysis of the enamel matrix proteins is delayed. Therefore, they are retained in the matrix during the maturation stage. This causes a rise of pH that delays the modulation of ruffle-ended ameloblasts to the smooth- ended form which comprise the superficial layer of aprismatic enamel27. In the maturation stage, sustained exposure to fluoride leads to the formation of a highly hypomineralized subsurface enamel, which is responsible for the clinical appearance of opaque white areas26. Fluoride affects the ameloblasts. In fact, fluoride is responsible for subameloblastic cyst formation. These cysts can develop into deep cervical and shallow coronal pits at the enamel surface, while the underlying enamel is highly hypermineralized26,27. Excessive intake of fluoride during the formation of enamel has a negative effect on the enzymically breakdown and removal of amelogenins28,29. Protein and water retention prevents the formation of the crystals of the enamel matrix, resulting in a porous subsurface.
The volume and depth of the subsurface pores increase as the severity of dental fluorosis rises19. The more severe the dental fluorosis is, the more porous the enamel surface appears19. In mild cases, the enamel is characterized by white lines, following the perikymata. In several cases, the white lines are merged, whilst in other cases, clearly opaque areas can be seen in between them. In moderate cases, the whole enamel surface may be opaque and white. In view of the fact that concentration of fluoride in the water of the town of Langadas ranges from 0,3 to 15,5 ppm, while the acceptable level of fluoride in potable water has been found to be 1,5 ppm7, it stands to reason that our patient’s teeth had been affected to such an extent that almost the entire enamel surface appeared white and chalky. After tooth eruption, the porous subsurface of fluorosed enamel can absorb pigments, triggering tooth discoloration. In cases of wide porous areas, an occlusal trauma could lead to fragmentation and the detachment of enamel resulting in the creation of pits19. Pigments permeate the porous substrate of fluorosed enamel, causing discoloration to happen. The colour of the enamel varies from yellowish to bright brown, dark brown or even black. The more severe the dental fluorosis, the more porous the enamel subsurface19.
In the literature a variety of management options are presented. Akpata suggested that bleaching should be performed as a treatment option in cases of mild fluorosis (TFI 1-2), based on the theory that pigments can be located in the outer layer of the porous enamel subsurface, hence they can be easily dislodged with the use of a bleaching agent30. The application of phosphoric acid to the hypomineralized enamel facilitates the infiltration of the bleaching agent into the porous subsurface enamel. Atia and May suggested that bleaching, microabrasion or the combination of these two should be performed as a treatment option in cases of mild fluorosis (TFI 1-3) in
Figure 6. Final aesthetic result
Discussion
An aesthetic appearance of the teeth is the key to a beautiful smile and something valued by people of all ages and genders. Aesthetic problems could have a negative impact on a patient’s psychology, limiting their social life20-22,25.
Fluoride levels in plasma are associated with disturbances of amelogenesis. Studies in rat incisors suggest that chronic plasma levels of 2 μmol/L or peak levels over 10 μmol/L are able to cause dental fluorosis. The severity of the defect on ameloblasts and the enamel matrix depends on the dose and duration of fluoride exposure26. It has been suggested that in the secretory stage, hydroxyapatite crystals are formed with a higher fluoride content leading to a greater number of amelogenins binding to the crystals. Consequently,
Figure 4. Appearance of the teeth after the 2nd application
Figure 5. 2% neutral sodium fluoride gel
160 Zoi Daskalaki et al. Balk J Dent Med, Vol 23, 2019
treatment, suggested for the aesthetic improvement of teeth which have either innate spots (dental fluorosis) or exogenous spots on the surface of the enamel41-43. It is considered to be the treatment of choice for mild dental fluorosis (TFI=1-3), whilst it can also be applied in teeth with moderate fluorosis (TFI=4)30 and it is usually combined with bleaching in order to achieve a more effective result44. In comparison with other restorative procedures, microabrasion causes a minimal loss of dental structure, it does not inflict postoperative pain or sensitivity on the patient and, in most cases, it is accomplished in a single session, causing insignificant discomfort to patients42-46. In general, microabrasion is suggested when the depth of discoloration is a maximum of 0,2-0,3 mm47. The amount of enamel lost by microabrasion ranges from 12 μm to 200 μm and it is affected by the duration of the process35,48,49. Furthermore, it has been found that the concentration of Ca and P in the outer layer of enamel is significant lower in young patients (18-24 years old) than in the older ones (>55 years old). This fact indicates that conservative, minimally invasive procedures are preferable when treating children and adolescents50. The instant and stable results obtainable after the complete removal of the spots, rather than by covering them with restorative material42, and the lack of pulpal and periodontal irritation are among the benefits of this method42,46. Phosphoric acid etching is performed on surface of the discoloured tooth, followed by the application of a fine-gritted paste made of pumice slurry and 18% hydrochloric acid in order to abrade the enamel surface. It is a technique that removes the porous enamel in conjunction with the unwanted pigments. Pastes with a lower concentration of hydrochloric acid can be found on the market. For instance, Prema Compound (Premier Dental Company) contains 10% hydrochloric acid and a silicon carbide abrasive powder. In addition, Opalustre (Ultradent) is comprised of 6.6% hydrochloric acid and silicon carbide microparticles49,51. Due to the use of acid during the microabrasion, it is crucial to use a rubber dam throughout the procedure. Not only does it protect soft tissues from irritation, but it also prevents materials from falling into the patient’s mouth and limits any contact with saliva. The paste can be applied on the tooth surface with the help of a polishing cup or a rotating brush on low speed (approximately 100 rpm)52 or by slightly pressing a tongue depressor53. In our case, after microabrasion, a significant improvement in the colour of the upper incisors was noticeable and the tooth surface appeared sleek and glossy. The factors which contribute to this result are mild mechanical abrasion of the enamel surface combined with erosion by the acid. In addition, the application of amorphous calcium phosphate (ACP) is recommended so that postoperative hypersensitivity is avoided52. It should be also mentioned that the Casein phosphopeptide - Amorphous calcium phosphate Complex
the paediatric patient31. Bharath et al. proposed that mild and moderate fluorosis in children can be managed with microabrasion or McInnes solution bleaching (consisting of HCL36%, H2O230% and Diethyle Ether), since both of them achieve aesthetic results and an absence of postoperative sensitivity32. Moreover, Bussadori et al. performed bleaching on an 8-year-old boy with fluorosis33. They used a dual activation system with 35% hydrogen peroxide and achieved a satisfactory outcome. Furthermore, Atia and May mention that individual stains in mild fluorosis could also be managed with composite resin; however, the removal of the discoloured enamel or application of an opaquer should be performed beforehand31.
Another treatment choice, which is mentioned in the literature, is the resin infiltration technique34,35. It is actually a micro-invasive treatment for the management of non-cavicated lesions and its aim is the deep penetration of a light-curing resin into the porous enamel lesions, so as to fill them34. Consequently, teeth become less opaque white and there is an improvement in their appearance36. However, further research is required in this area.
Akpata suggested microabrasion for the treatment of TFI=4 scored teeth, as pigments could be found so deeply inside the porous subsurface enamel that it is fanciful to believe that they could be completely removed exclusively by bleaching30. Microabrasion removes the porous subsurface enamel and pigments simultaneously. Hence, with microabrasion, management of dental fluorosis would be as optimally preservative as possible. Similarly, Khandelwal et al. effectively performed microabrasion on a paediatric patient with moderate fluorosis37. This is a rather conservative technique and, should it fail to meet the patient’s requirements, some other more invasive methods may be required38. For instance, Wallace and Deery recommend the use of composite resin in cases of moderate and severe dental fluorosis where bleaching and microabrasion have failed to meet the patient’s and dentist’s expectations35.
For cases with TFI ≥5, Atia and May proposed that microabrasion should be followed up with composite resin veneers31. As regards teeth with TFI=5-7, which have lost more than 50% of their enamel surface, and teeth with TFI=8-9, application of ceramic veneers and crowns is recommended31,39,40. However, this technique should only be used in adults, due to the fact that immature teeth have a quite wide pulp chamber and the position of the gingival margin is not in a constant level yet31,35. Taking all of the above into consideration, the treatment options for discoloured fluorosed teeth are bleaching, microabrasion, resin infiltration, composite resin, aesthetic veneers and crowns. In the literature, the criteria for the application of these techniques vary.
Microabrasion is the controlled removal of superficial stains from the enamel. In the literature, it is the first choice for conservative, minimally invasive
Balk J Dent Med, Vol 23, 2019 Treatment of Dental Fluorosis 161
10. Zhang R, Cheng L, Zhang T, Xu T, Li M, Yin W, et al. Brick tea consumption is a risk factor for dental caries and dental fluorosis among 12-year-old Tebetan children in Ganzi. Environ Geochem Health, 2018. doi: 10.1007/s10653-018- 0216-7.
11. Lodi CS, Ramires I, Pessan JP, das Neves LT, Buzalaf MA. Fluoride concentrations in industrialized beverages consumed by children in the city of Bauru, Brazil. J Appl Oral Sci, 2007;15:209-212.
12. Pretty IA. High fluoride concentration toothpastes for children and adolescents. Caries Res, 2016;50:9-14.
13. Siew C, Strock S, Ristic H, Kang P, Chou HN, Chen JW, et al. Assessing the potential risk factor for enamel fluorosis: A preliminary evaluation of fluoride content in infant formulas. J Am Dent Assoc, 2009;140:1228-1236.
14. Zohoori FV, Omid N, Sanderson RA, Valentine RA, Maguire A. Fluoride retention in infants living in fluoridated and non-fluoridated areas: effects of weaning. Br J Nutr, 2019;121:74-81.
15. Burt BA. The changing patterns of systemic fluoride intake. J Dent Res, 1992;71:1228-1237.
16. Rozier RG. Epidemiological indices for measuring the clinical manifestations of dental fluorosis: Overview and critique. Adv Dent Res, 1994;8:39-55.
17. Granath L, Widenheim J, Birkhed D. Diagnosis of mild enamel fluorosis in permanent maxillary incisors using two scoring systems. Community Dent Oral Epidemiol, 1985;13:273-276.
18. Dean H. Classification of Mottled Enamel Diagnosis. J Am Dent Assoc, 1934;21:1421-1426.
19. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol, 1978;6:315-328.
20. Tellez M, Santamaria RM, Gomez J, Martignon S. Dental fluorosis, dental caries, and quality of life factors among schoolchildren in a Colombian fluorotic areal. Community Dent Health, 2012;29:95-99.
21. Nurelhuda N, Ahmed MF, Trovik TA, Åstrøm AN. Evaluation of oral health-related quality of life among Sudanese schoolchildren using Child-OIDP inventory. Health Qual Life Out, 2010;8:152. doi: 10.1186/1477-7525- 8-152
22. Nilchian F, Asgary I, Mastan F. The effect of dental fluorosis on the quality of life of female high school and precollege students of high fluoride-concentrated area. J Int Soc Prev Community Dent, 2018;8:314-319.
23. Gupta SK, Gupta RC, Seth AK, Gupta A. Reversal of fluorosis in children. Acta Paediatr Jpn, 1996;38:513-519.
24. Suscheela AK, Bhatnagar M. Reversal of fluoride induced cell injury through elimination of fluoride and consumption of diet rich in essential nutrients and antioxidants. Mol Cell Biochem, 2002;234:335-340.
25. Welbrury RR, Shaw L. A simple technique for removal of mottling, opacities and pigmentation from enamel. Dent Update, 1990;2013:161-163.
26. DenBesten P, Li W. Chronic Fluoride Toxicity: Dental Fluorosis. Monogr Oral Sci, 2011;22:81-96.
27. Bronckers AL, Lyaruu DM, DenBesten PK. The Impact of Fluoride on Ameloblasts and the Mechanisms of Enamel Fluorosis. J Dent Res, 2009;88:877-893.
(CPP-ACP) brings about a reduction in the white opacity of the fluorosed enamel, boosting the remineralization54,55.
The clinical dentist should be aware of all the possible treatment choices, be able to…
Related Documents
